<div id="stylized-form">
	<h2><!--[gt text='Agency Form']--></h2>
	<form method="post" action="<!--[pnmodurl modname=spaservice type=adminform func=submit ctrl=agency]-->">
  <input name="form[id]" type="hidden" size="40" value="<!--[$smarty.get.id]-->" />
  <div class="wrapper-block">
		<label for="user">
			<!--[gt text='AgencyGroup']-->
		</label>
		<!--[selector_object_array_ex modname=SpaService class=agencygroup name=form[agencyGroup_id] selectedValue=$form.agencyGroup_id displayField=title]-->
	</div>
	<div class="wrapper-block">
		<label for="user">
			<!--[gt text='Company Name']-->
		</label>
		<input name="form[companyName]" type="text" size="40" value="<!--[$form.companyName]-->" />
	</div>
  <div class="wrapper-block">
		<label for="user">
			<!--[gt text='License Number']-->
		</label>
		<input name="form[licenseNumber]" type="text" size="40" value="<!--[$form.licenseNumber]-->" />
	</div>
  <div class="wrapper-block">
		<label for="user">
			<!--[gt text='Telephone']-->
		</label>
		<input name="form[telephone]" type="text" size="40" value="<!--[$form.telephone]-->" />
	</div>
  <div class="wrapper-block">
		<label for="user">
			<!--[gt text='Fax']-->
		</label>
		<input name="form[fax]" type="text" size="40" value="<!--[$form.fax]-->" />
	</div>
   <div class="wrapper-block">
		<label for="user">
			<!--[gt text='Email']-->
		</label>
		<input name="form[email]" type="text" size="40" value="<!--[$form.email]-->" />
	</div>
  <div class="wrapper-block">
		<label for="user">
			<!--[gt text='Website']-->
		</label>
		<input name="form[website]" type="text" size="40" value="<!--[$form.website]-->" />
	</div>
  <div class="wrapper-block">
		<label for="user">
			<!--[gt text='Address']-->
		</label>
		<input name="form[address]" type="text" size="40" value="<!--[$form.address]-->" />
	</div>
  <div class="wrapper-block">
		<label for="user">
			<!--[gt text='City']-->
		</label>
		<input name="form[city]" type="text" size="40" value="<!--[$form.city]-->" />
	</div>
  <div class="wrapper-block">
		<label for="user">
			<!--[gt text='State']-->
		</label>
		<input name="form[state]" type="text" size="40" value="<!--[$form.state]-->" />
	</div>
  <div class="wrapper-block">
		<label for="user">
			<!--[gt text='Country']-->
		</label>
		<input name="form[country]" type="text" size="40" value="<!--[$form.country]-->" />
	</div>
  <div class="wrapper-block">
		<label for="user">
			<!--[gt text='Post']-->
		</label>
		<input name="form[post]" type="text" size="40" value="<!--[$form.post]-->" />
	</div>
  <div class="wrapper-block">
		<label for="user">
			<!--[gt text='Special Detail']-->
		</label>
		<input name="form[specialDetail]" type="text" size="40" value="<!--[$form.specialDetail]-->" />
	</div>
  <div class="wrapper-block">
		<label for="user">
			<!--[gt text='Is active']-->
		</label>
    <!--[if $form.isActive eq 1]-->
		  <input type="checkbox" name="form[isActive]" checked="yes" value="1"> is Active<br>
    <!--[else]-->
      <input type="checkbox" name="form[isActive]" value="1"> is Active<br>
    <!--[/if]-->
	</div>
	<input type="submit" value="submit">
	</form>
</div>